Formulary guidance and transparency from P&T to point of care

Trends That Matter for Medicare Part D Costs

Posted by Leslie Small on Aug 15, 2019

A recently published study in Health Affairs shines a light on a peculiar quirk of the Medicare Part D benefit structure: For some high-priced specialty medications, seniors might pay less out-of-pocket for brand-name drugs than their generic counterparts.

The study found that, assuming a 61% discount between brand-name and generic drugs, Part D beneficiaries with prescriptions costing between $22,000 and $80,000 per year would have lower out-of-pocket spending if they use brand-name drugs over a generic, AIS Health reported.
Read More

Topics: Industry Trends, Product Release, Data & Analytics

Radar On Market Access: More Than 1,000 RM/AT Products Are in Pipeline

Posted by Angela Maas on Aug 15, 2019

This past quarter saw two new gene therapies: Novartis AG subsidiary AveXis, Inc.'s Zolgensma (onasemnogene abeparvovec-xioi) received FDA approval May 24 for the treatment of spinal muscular atrophy, and bluebird bio's Zynteglo (autologous CD34+ cells encoding βA-T87Q- globin gene) received conditional marketing authorization from the European Commission for transfusion-dependent beta thalassemia.

While only a handful of therapies in the broader regenerative medicine/advanced therapy (RM/AT) space are available globally, a new report shows that is likely to change, as there are more than 1,000 products in the pipeline, AIS Health reported.
Read More

Topics: Specialty, Industry Trends, Market Access, Provider, Payer

Radar On Market Access: Trump's Drug Importation Plan Faces Significant Hurdles

Posted by Aine Cryts on Aug 13, 2019

Amid an ongoing outcry against rising drug costs, the Trump administration recently introduced two importation pathways to reduce what U.S. residents pay for drugs, AIS Health reported.

Under the Safe Importation Action Plan, the first pathway would allow states, wholesalers and pharmacists to propose to HHS demonstration projects for importing certain drugs from Canada. Under the second pathway, drug manufacturers could import non-U.S. countries' versions of their drugs into the United States.
Read More

Topics: Industry Trends, Provider, Payer

Perspectives on Electronic Real-Time Benefit Tool

Posted by Lauren Flynn Kelly on Aug 8, 2019

CMS in a final Medicare Advantage and Part D drug pricing rule posted in May finalized the requirement that Part D sponsors implement an electronic Real-Time Benefit Tool (RTBT). While the tool offers the potential to accelerate electronic prescribing, improve formulary adherence and lower prescription drug spending, it may pose a heavy information technology burden for some plans and require effort on the part of plans to encourage prescriber adoption, AIS Health reported.

According to the rule, each Part D sponsor must implement at least one RTBT capable of integrating with at least one prescriber's e-prescribing system or electronic health record (EHR) to "provide prescribers who care for its enrollees complete, accurate, timely and clinically appropriate patient-specific real-time formulary and benefit (F&B) information (including cost, formulary alternative and utilization management requirements)" by Jan. 1, 2021.
Read More

Topics: Industry Trends, Provider, Payer

Radar On Market Access: Senate Drug Pricing Legislation Takes Wide-Reaching Approach

Posted by Angela Maas on Aug 8, 2019

While there is certainly no shortage of proposals on drug pricing from the administration, a proposed Senate bill is taking a multipronged approach to the issue. The Prescription Drug Pricing Reduction Act (PDPRA) of 2019, introduced by Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore.), proposes multiple changes to Medicare Part B and Part D, as well as Medicaid. According to a preliminary estimate by the Congressional Budget Office (CBO), 10-year savings to the federal government would total more than $100 billion, AIS Health reported.

Proposals within the bill include caps on drug price increases in both Part B and Part D, as well as caps on out-of-pocket (OOP) spend for beneficiaries via a complete restructuring of Part D. It also proposes including patient coupons within the average sales price calculation, boosting the add-on payment for a Part B biosimilar from 6% of the reference drug’s ASP to 8% for a five-year period and banning spread pricing in Medicaid.
Read More

Topics: Industry Trends, Provider, Payer

Radar On Market Access: Congress Eyes Measures That Could Affect PBMs

Posted by Leslie Small on Aug 6, 2019

Now that the Trump administration has abandoned its bid to overhaul the Medicare Part D drug rebate system, all eyes are on what Congress will do to address the ever-vexing problem of high drug prices, AIS Health reported.

While some ideas lawmakers are considering could be very problematic for PBMs, industry analysts are dubious about their prospects. Other less-drastic changes, though, could make it into law.
Read More

Topics: Industry Trends, Provider, Payer

Trends That Matter for CMS's Oncology Care Model

Posted by Angela Maas on Aug 1, 2019

CMS's Oncology Care Model (OCM) is about halfway through its five-year pilot. Developed by the CMS Center for Medicare & Medicaid Innovation, the voluntary pilot is aimed at providing better quality and more coordinated cancer care for Medicare fee-for-service beneficiaries, as well as other payers, while at a lower cost.

One criticism of the model is that providers' costs are compared with targeted costs that are based partly on their spending from 2012 to 2015, the OCM baseline period. When the actual costs come in below the targeted costs, that earns providers a performance-based payment. But with so many costly oncology therapies launching after the baseline period, this is making it hard for providers to gain a performance-based payment, AIS Health reported.
Read More

Topics: Industry Trends, Product Release, Data & Analytics

Radar On Market Access: Can Louisiana’s Hepatitis C Drug Payment Model Be Replicated?

Posted by Leslie Small on Aug 1, 2019

Beginning last month, Louisiana has been able to treat hundreds of patients who were waiting to receive a pricey cure for hepatitis C thanks to after hammering out an innovative payment model with a drug manufacturer, AIS Health reported.

But the road to get there was long and difficult, according to Rebekah Gee, M.D., secretary of the Louisiana Dept. of Health, who, during a July 22 event hosted by the Brookings Institution, detailed the challenges she faced in trying to get a costly curative therapy to more people while facing down a $2 billion budget deficit. "We were told 'No' at least 50 times from a variety of people, whether it was the industry, or policymakers or individuals at the CDC…because it had never been done before," she said.
Read More

Topics: Industry Trends, Provider, Payer

Radar On Market Access: Will Blockchain Transform Relationships Industry Wide?

Posted by Judy Packer Tursman on Jul 30, 2019

Industry consultants from Milliman Inc. assert in a July 11 report that blockchain — which is described as a real-time digital ledger for building secure networks — "could potentially transform the relationship between payers, pharmaceutical manufacturers, wholesalers, and pharmacies by offering an alternative, transparent mechanism for processing, pricing, and validating prescription transactions."

Using blockchain technology, payers and pharmacies would reduce the time they spend validating insurance coverage, making phone calls and managing data, Milliman explains. The firm is urging PBMs to work to "evaluate a blockchain alternative now with an eye toward a more efficient drug financing system" capable of handling additional technology improvements, AIS Health reported.
Read More

Topics: Industry Trends, Data & Analytics, Provider, Payer

Perspectives on New York's Pricing Transparency Bill

Posted by Jane Anderson on Jul 25, 2019

Lawmakers in New York in June approved wide-ranging legislation designed to require pricing transparency from PBMs and to eliminate key PBM practices. But the bill could potentially limit plans' ability to respond to pricing moves by manufacturers, one consultant tells AIS Health.

The New York bill (S.B. 6531) would require that PBMs disclose key pricing and rebate information and pass through all rebates and discounts to the plans and payers, and that they act in the best interests of the covered individual and the health plan or provider.
Read More

Topics: Industry Trends, Provider, Payer